CSFA (Certified Surgical First Assistant) Exam — Questions and Answers

Question 1: What chemical class do most high-level disinfectants (HLDs) used for endoscopes belong to?

Phenolics
Quaternary ammonium compounds
Glutaraldehydes or ortho-phthalaldehyde (OPA) (Correct answer)
Alcohols

Correct answer: Glutaraldehydes or ortho-phthalaldehyde (OPA)

Glutaraldehyde and OPA are the primary HLDs used for endoscopes because they achieve high-level disinfection of semi-critical devices.

Question 2: The saphenous nerve, a branch of the femoral nerve, accompanies which vessel and is at risk during saphenous vein harvest?

Lesser saphenous vein
Popliteal vein
Greater saphenous vein (Correct answer)
Femoral artery

Correct answer: Greater saphenous vein

The saphenous nerve runs alongside the greater saphenous vein, particularly below the knee, and can be injured during vein harvest causing medial leg paresthesia.

Question 3: A patient reports feeling a 'pop' and notices a pink watery discharge from their abdominal wound on postoperative day 5. The MOST likely complication is:

Normal serosanguineous drainage
Wound dehiscence with evisceration risk (Correct answer)
Hematoma formation
Surgical site infection with abscess

Correct answer: Wound dehiscence with evisceration risk

A 'popping' sensation followed by salmon-colored (serosanguineous) discharge is a classic presentation of fascial dehiscence requiring immediate wound assessment.

Question 4: During an open cholecystectomy, the surgical first assistant identifies Calot's triangle. Which three structures form the boundaries of this triangle?

Cystic artery, hepatoduodenal ligament, and duodenum
Cystic duct, common hepatic duct, and inferior surface of the liver (Correct answer)
Cystic duct, hepatic artery, and portal vein
Common bile duct, cystic artery, and liver edge

Correct answer: Cystic duct, common hepatic duct, and inferior surface of the liver

Calot's triangle is bounded by the cystic duct inferiorly, the common hepatic duct medially, and the inferior surface of the liver superiorly.

Question 5: What is the primary purpose of using a sterile drape with an iodine-impregnated adhesive incise film (e.g., Ioban)?

To reduce SSI risk by immobilizing skin flora at the incision site (Correct answer)
To prevent instrument tips from touching the patient's skin
To mark the incision site for the surgeon
To provide hemostasis at the skin edges

Correct answer: To reduce SSI risk by immobilizing skin flora at the incision site

Iodine-impregnated incise drapes kill resident skin flora and mechanically isolate the incision site to prevent microbial migration into the wound.

Question 6: What is the clinical significance of the recurrent laryngeal nerve's relationship to the inferior thyroid artery during thyroidectomy?

The nerve always passes anterior to the artery
The nerve always passes posterior to the artery
The artery must always be ligated distal to the nerve crossing
The nerve has variable relationships to the artery requiring careful identification (Correct answer)

Correct answer: The nerve has variable relationships to the artery requiring careful identification

The recurrent laryngeal nerve has a highly variable relationship to the inferior thyroid artery, requiring visual identification before ligation to prevent vocal cord paralysis.

Question 7: Regarding preoperative hair removal at the surgical site, which method and timing are most consistent with evidence-based guidelines to reduce the risk of surgical site infections (SSIs)?

Using a depilatory cream 2 hours before surgery.
Using clippers immediately before the procedure, outside the operating room. (Correct answer)
Hair should always be removed to ensure a clean field.
Shaving with a razor the night before surgery.

Correct answer: Using clippers immediately before the procedure, outside the operating room.

Guidelines from organizations like AORN recommend that hair should only be removed if it interferes with the procedure. When removal is necessary, using electric clippers is the preferred method as it minimizes skin trauma. This should be done as close to the time of surgery as possible, and preferably outside the sterile operating room to prevent loose hair from contaminating the field.

Question 8: The surgical first assistant is retracting during a carotid endarterectomy. Which intraoperative neurological monitoring modality is MOST commonly used to detect cerebral ischemia during carotid clamping?

Bispectral index (BIS) monitoring
Somatosensory evoked potentials (SSEPs)
Electroencephalography (EEG) (Correct answer)
Transcranial motor evoked potentials (TcMEPs)

Correct answer: Electroencephalography (EEG)

Continuous EEG monitoring during carotid endarterectomy detects cortical ischemia during carotid clamping by showing characteristic frequency slowing or amplitude reduction.

Question 9: Which suture material is the first choice for closing a contaminated abdominal wound due to its resistance to infection?

Polypropylene (Prolene) (Correct answer)
Polyglactin 910 (Vicryl)
Chromic catgut
Silk

Correct answer: Polypropylene (Prolene)

Polypropylene is monofilament and non-absorbable, resisting bacterial colonization better than braided or natural sutures in contaminated fields.

Question 10: During a femoral hernia repair, which structure forms the medial boundary of the femoral ring?

Lacunar (Gimbernat's) ligament (Correct answer)
Iliopubic tract
Femoral vein
Inguinal ligament

Correct answer: Lacunar (Gimbernat's) ligament

The lacunar ligament forms the sharp medial boundary of the femoral ring and must be carefully divided to reduce an incarcerated femoral hernia.

Question 11: A patient undergoing open abdominal surgery develops a sudden drop in SpO2 and elevated peak airway pressures. The surgical first assistant should first:

Request additional electrocautery equipment
Increase suction in the operative field
Apply direct pressure to the aorta
Notify the anesthesia provider immediately (Correct answer)

Correct answer: Notify the anesthesia provider immediately

Sudden SpO2 drop with elevated airway pressures suggests a ventilatory emergency requiring immediate anesthesia intervention.

Question 12: Which physiologic mechanism primarily maintains mean arterial pressure when a patient transitions from supine to upright positioning on the operating table?

Parasympathetic withdrawal from the SA node
Atrial natriuretic peptide release
Baroreceptor-mediated sympathetic vasoconstriction (Correct answer)
Increased stroke volume

Correct answer: Baroreceptor-mediated sympathetic vasoconstriction

Baroreceptors in the carotid sinus and aortic arch detect pressure drops and trigger sympathetic vasoconstriction to maintain MAP.

Question 13: During a femoral hernia repair, which structure forms the medial boundary of the femoral ring and must not be cut unless a corona mortis is present?

Cooper's ligament
Femoral vein
Lacunar (Gimbernat's) ligament (Correct answer)
Inguinal ligament

Correct answer: Lacunar (Gimbernat's) ligament

The lacunar ligament forms the sharp medial boundary of the femoral ring; it is normally incised to reduce an incarcerated femoral hernia but may contain an anomalous obturator artery (corona mortis).

Question 14: The NPO (nil per os) guideline for clear liquids before elective surgery in adults is typically:

8 hours
1 hour
4 hours
2 hours (Correct answer)

Correct answer: 2 hours

ASA guidelines recommend NPO for clear liquids at least 2 hours before elective procedures to reduce aspiration risk.

Question 15: Tranexamic acid (TXA) is used intraoperatively primarily to:

Inhibit fibrinolysis and reduce surgical blood loss (Correct answer)
Reverse heparin anticoagulation
Increase platelet aggregation directly
Promote vasodilation and reduce blood pressure

Correct answer: Inhibit fibrinolysis and reduce surgical blood loss

Tranexamic acid inhibits fibrinolysis by blocking plasminogen activation, thereby stabilizing clots and reducing intraoperative blood loss.

Question 16: During an anterior cervical discectomy and fusion (ACDF), which vessel is at greatest risk if retraction on the medial side is excessive?

Carotid artery (Correct answer)
Esophageal artery
Vertebral artery
Internal jugular vein

Correct answer: Carotid artery

The carotid artery lies just lateral to the surgical dissection plane in ACDF; excessive medial retraction or incorrect plane development can injure it.

Question 17: A Jehovah's Witness patient undergoing surgery has refused blood transfusion even in life-threatening circumstances. The surgical first assistant should:

Contact ethics only after the case is complete
Proceed with surgery but order blood products to be kept on standby
Override the refusal in an emergency as the patient's life takes precedence
Document the refusal, ensure a signed refusal form is in the chart, and inform the surgeon and anesthesia team (Correct answer)

Correct answer: Document the refusal, ensure a signed refusal form is in the chart, and inform the surgeon and anesthesia team

A competent adult's refusal of blood products is legally and ethically binding; the team must document it, inform all providers, and plan bloodless surgical strategies.

Question 18: A biological indicator (BI) is used to verify the efficacy of a prevacuum steam sterilization cycle. Which spore-forming microorganism is the standard for this testing method?

Geobacillus stearothermophilus (Correct answer)
Clostridium difficile
Mycobacterium tuberculosis
Bacillus atrophaeus

Correct answer: Geobacillus stearothermophilus

Geobacillus stearothermophilus is a thermophilic bacterium whose spores are highly resistant to heat. This makes it the industry and FDA-recognized standard organism for validating the effectiveness of steam sterilization processes. Bacillus atrophaeus is used for ethylene oxide (EtO) and dry heat sterilization.

Question 19: Which space, located between the parietal peritoneum and the transversalis fascia, allows for extraperitoneal dissection during laparoscopic hernia repair (TEP)?

Space of Bogros
Prevesical space
Preperitoneal (Retzius) space (Correct answer)
Retropubic space

Correct answer: Preperitoneal (Retzius) space

The preperitoneal space (space of Retzius) lies between the transversalis fascia and parietal peritoneum, and is developed during totally extraperitoneal hernia repair.

Question 20: In the immediate postoperative period, which assessment finding would MOST concern the surgical first assistant monitoring a patient after thyroidectomy?

Hoarseness and stridor with perioral tingling (Correct answer)
Mild sore throat from intubation
Serosanguineous drainage at the wound site
Heart rate of 88 bpm

Correct answer: Hoarseness and stridor with perioral tingling

Stridor with hoarseness and perioral tingling after thyroidectomy suggests hypocalcemia from parathyroid injury plus potential airway compromise from hematoma or nerve damage.

Question 21: In vascular surgery, which action by the surgical first assistant best prevents intimal injury when handling a vessel graft?

Stretching the graft to its full length before placement
Grasping the graft firmly with non-atraumatic clamps
Handling only the adventitial surface and avoiding forceps on the intimal surface (Correct answer)
Immersing the graft in dry gauze

Correct answer: Handling only the adventitial surface and avoiding forceps on the intimal surface

Intimal injury promotes thrombosis; grafts should be handled by the outer adventitia only to preserve the inner lining.

Question 22: The obturator nerve (L2–L4) exits the pelvis through the obturator foramen and primarily innervates which muscle group?

Hip flexors
Foot dorsiflexors
Knee extensors
Medial thigh adductors (Correct answer)

Correct answer: Medial thigh adductors

The obturator nerve innervates the medial compartment adductor muscles of the thigh including adductor longus, brevis, magnus, and gracilis.

Question 23: A patient begins seizing in the PACU after intracranial surgery. What is the FIRST action the surgical first assistant should take?

Administer IV diazepam immediately without waiting
Protect the airway, turn the patient to the lateral position, and call for help (Correct answer)
Restrain the patient to prevent injury
Place a padded tongue blade between the teeth

Correct answer: Protect the airway, turn the patient to the lateral position, and call for help

Airway protection in the lateral recovery position and immediately calling for assistance are the first priorities during a postoperative seizure.

Question 24: The ductus arteriosus connects which two vascular structures in fetal circulation?

Pulmonary artery to aorta (Correct answer)
Pulmonary vein to left atrium
Right atrium to left atrium
Superior vena cava to pulmonary artery

Correct answer: Pulmonary artery to aorta

The ductus arteriosus shunts blood from the pulmonary artery to the descending aorta, bypassing the non-functional fetal lungs.

Question 25: A CSFA is assisting with an inguinal hernia repair. The surgeon notes that the herniation is occurring medial to the inferior epigastric vessels. Based on this anatomical landmark, the CSFA understands this is a direct inguinal hernia, which is caused by a weakness in which structure?

The femoral canal
The deep inguinal ring
The transversalis fascia of Hesselbach's triangle (Correct answer)
The internal oblique muscle aponeurosis

Correct answer: The transversalis fascia of Hesselbach's triangle

Direct inguinal hernias are acquired defects that occur due to a weakness in the posterior wall of the inguinal canal, specifically through an area known as Hesselbach's triangle. The floor of this triangle is formed by the transversalis fascia. Indirect hernias, in contrast, pass through the deep inguinal ring, lateral to the inferior epigastric vessels.

Question 26: While assisting with patient transport, a chest tube is accidentally pulled out completely from the patient's pleural space. Which of the following is the correct immediate emergency action?

Submerge the end of the disconnected tubing in sterile water.
Immediately reinsert the chest tube into the existing site.
Place the patient on their affected side to splint the chest wall.
Apply pressure with a gloved hand and cover the site with an occlusive dressing taped on three sides. (Correct answer)

Correct answer: Apply pressure with a gloved hand and cover the site with an occlusive dressing taped on three sides.

If a chest tube is accidentally removed, the priority is to prevent air from entering the pleural space and causing a tension pneumothorax. The correct emergency procedure is to immediately cover the insertion site with a sterile occlusive (petroleum) dressing, taping it on only three sides. This creates a flutter valve effect, allowing air to escape from the pleural space during exhalation but preventing it from entering during inhalation. Reinsertion is a sterile procedure done by a provider, and submerging the tube is the action for a system disconnection, not a complete removal.

Question 27: Which foramen in the base of the skull transmits the internal carotid artery into the cranial cavity?

Jugular foramen
Carotid canal (Correct answer)
Foramen spinosum
Foramen ovale

Correct answer: Carotid canal

The internal carotid artery enters the skull through the carotid canal in the petrous portion of the temporal bone and then enters the middle cranial fossa.

Question 28: A patient develops bronchospasm during anesthesia induction. Which drug class is the FIRST-LINE bronchodilator used intraoperatively?

Beta-2 agonists (Correct answer)
Corticosteroids
Anticholinergics
Antihistamines

Correct answer: Beta-2 agonists

Beta-2 agonists such as albuterol are first-line agents for acute bronchospasm because they rapidly relax bronchial smooth muscle.

Question 29: The blood-brain barrier is primarily formed by which cellular component of the neurovascular unit?

Astrocyte end-feet alone
Microglial processes
Tight junctions between cerebral endothelial cells (Correct answer)
Pericyte basement membrane

Correct answer: Tight junctions between cerebral endothelial cells

The blood-brain barrier is structurally formed by tight junctions (zonula occludens) between adjacent cerebral capillary endothelial cells, which restrict paracellular diffusion.

Question 30: Which of the following actions violates aseptic technique during surgical draping?

Draping from the incision site outward
Unfolding drapes away from the sterile field
Reaching across the unsterile side to adjust a drape (Correct answer)
Holding drapes above waist level during placement

Correct answer: Reaching across the unsterile side to adjust a drape

Reaching across an unsterile area contaminates the sterile glove and gown, violating aseptic technique.

Question 31: When applying sterile gloves using the closed-glove technique, the hands must remain:

Bare and visible to ensure accurate placement of the glove
At the side until the circulator presents the glove
Extended beyond the cuffs of the gown before the first glove is applied
Inside the cuffs of the gown throughout the entire gloving process (Correct answer)

Correct answer: Inside the cuffs of the gown throughout the entire gloving process

In the closed-glove technique, hands remain inside the gown cuffs until gloves are fully applied, preventing ungloved hands from contaminating the sterile gown exterior.

Question 32: The semi-Fowler position elevates the head of the bed to approximately:

30–45 degrees (Correct answer)
60–90 degrees
10–15 degrees
0 degrees (flat)

Correct answer: 30–45 degrees

The semi-Fowler position elevates the head of the bed to approximately 30–45 degrees and is used for head, neck, and some upper chest procedures.

Question 33: The intrinsic conduction system of the heart enables communication between its muscle fibers.

receive oxygen from other cells
receive energy from other cells
contract only when they receive a nerve impulse
contract on their own (Correct answer)

Correct answer: contract on their own

The intrinsic conduction system of the heart is composed of specialized cardiac muscle cells that possess automaticity, meaning they can generate their own electrical impulses. This inherent ability allows the heart muscle fibers to contract spontaneously and rhythmically without external nervous stimulation. This self-excitation ensures the heart can maintain a consistent beat independently.

Question 34: During a procedure, a scrubbed team member's glove is punctured. What is the immediate priority?

Continue if the puncture is on a finger not used for handling instruments
Apply a sterile glove over the punctured glove
Notify the surgeon and change gloves promptly (Correct answer)
Use the other hand exclusively for the remainder of the case

Correct answer: Notify the surgeon and change gloves promptly

A punctured glove must be changed promptly after notifying the surgeon to maintain aseptic technique and patient safety.

Question 35: Which intravenous anesthetic agent is known for its sympathomimetic properties, causing bronchodilation and an increase in heart rate and blood pressure, making it a favorable choice for hemodynamically unstable or asthmatic patients?

Ketamine (Correct answer)
Midazolam
Propofol
Etomidate

Correct answer: Ketamine

Ketamine is a dissociative anesthetic that stimulates the sympathetic nervous system, leading to increased heart rate, blood pressure, and cardiac output. It also possesses potent bronchodilatory effects, which is beneficial for patients with reactive airway disease. Propofol and etomidate can cause hypotension, while midazolam is primarily a sedative.

Question 36: When positioning a patient, which of the following should be taken into account? 1. Patency of the airway is the prime concern when positioning a patient 2. Pressue injuries are most common after surgical procedures lasting one hour or longer. 3. An anesthetized patient with muscle paralysis is at increased risk for muscle strain 4. The most common sites of peripheral nerve injury are the divisions of the brachial plexus and the ulnar, radial, peroneal, and facial nerves

incompetent valves
1 and 3 only
respiratory compromise
1, 2, and 4 only (Correct answer)

Correct answer: 1, 2, and 4 only

When positioning a patient for surgery, ensuring a patent airway (1) is the top priority to maintain oxygenation. Pressure injuries (2) are a significant risk, especially during procedures lasting an hour or longer, necessitating careful padding. Anesthetized patients with muscle paralysis are highly vulnerable to peripheral nerve injuries (4) due to the absence of protective reflexes, making precise positioning critical. Statement 3 is incorrect as muscle paralysis *increases* the risk of muscle strain, not decreases it.

Question 37: Following a thyroidectomy, a patient develops perioral numbness, tingling of the fingertips, and a positive Chvostek's sign. These findings are MOST consistent with:

Hyperkalemia from blood transfusion
Hypocalcemia due to thyroid hormone deficiency
Hypomagnesemia from excessive diuresis
Hypocalcemia due to parathyroid gland injury (Correct answer)

Correct answer: Hypocalcemia due to parathyroid gland injury

Inadvertent parathyroid removal or devascularization during thyroidectomy causes hypocalcemia, which presents with perioral numbness, tetany, and a positive Chvostek's sign.

Question 38: The surgical first assistant notes that a patient's blood pressure is 80/50 mmHg and heart rate is 128 bpm one hour post-abdominal surgery. The abdomen is distended. What emergency condition should be suspected?

Septic shock
Neurogenic shock
Pulmonary embolism
Intra-abdominal hemorrhage (Correct answer)

Correct answer: Intra-abdominal hemorrhage

Hypotension with tachycardia and abdominal distension in the early postoperative period strongly suggests intra-abdominal hemorrhage requiring urgent evaluation.

Question 39: A patient requires a rapid sequence intubation (RSI). The anesthesiologist plans to use succinylcholine. The CSFA should be aware that an absolute contraindication for this depolarizing neuromuscular blocker is a personal or family history of what condition?

Malignant Hyperthermia (Correct answer)
Asthma
Hypertension
Diabetes Mellitus

Correct answer: Malignant Hyperthermia

Succinylcholine is a known and potent trigger for malignant hyperthermia (MH), a rare but life-threatening inherited hypermetabolic disorder of skeletal muscle. Its use is strictly contraindicated in any patient with a personal or family history of MH.

Question 40: Which reversal agent is used to antagonize the effects of non-depolarizing neuromuscular blocking agents?

Flumazenil
Naloxone
Sugammadex only
Neostigmine (Correct answer)

Correct answer: Neostigmine

Neostigmine is an acetylcholinesterase inhibitor that reverses non-depolarizing NMBAs by increasing acetylcholine at the neuromuscular junction.

Question 41: A patient on postoperative day 3 following a colectomy has a distended abdomen, has not passed flatus, and reports nausea with no bowel sounds audible upon auscultation. These findings are most indicative of which postoperative complication?

Postoperative ileus (Correct answer)
Anastomotic leak
Mechanical small bowel obstruction
Acute pancreatitis

Correct answer: Postoperative ileus

Postoperative ileus is a temporary and expected cessation of bowel motility following abdominal surgery. The classic signs include abdominal distention, nausea and vomiting, inability to tolerate an oral diet or pass flatus, and absent or hypoactive bowel sounds. [5, 11, 24] While an anastomotic leak or mechanical obstruction are serious considerations, this clinical picture is the hallmark of a functional postoperative ileus. [14, 22]

Question 42: Which of the following microorganisms is a gram-positive coccus, commonly found on the skin, and is the most frequent cause of surgical site infections (SSIs)?

Candida albicans
Staphylococcus aureus (Correct answer)
Escherichia coli
Pseudomonas aeruginosa

Correct answer: Staphylococcus aureus

Staphylococcus aureus is a gram-positive coccus that is a common part of the normal flora of the skin and nares. It is the leading cause of SSIs. Escherichia coli is a gram-negative rod primarily found in the gastrointestinal tract. Pseudomonas aeruginosa is a gram-negative rod often associated with hospital-acquired infections. Candida albicans is a fungus (yeast).

Question 43: Which of the following describes the primary physiological goal of applying and inflating a pneumatic tourniquet on an extremity for a surgical procedure?

To prevent deep vein thrombosis (DVT)
To create a bloodless surgical field (Correct answer)
To reduce the patient's systemic metabolic rate
To decrease postoperative pain sensation

Correct answer: To create a bloodless surgical field

The principal function of a pneumatic tourniquet in surgery is to occlude arterial blood flow to a limb, thereby creating a bloodless or near-bloodless operative field. This significantly improves visualization for the surgeon, increases precision, and reduces intraoperative blood loss.

Question 44: Which of the following is the correct rate for adult chest compressions during CPR according to the AHA guidelines?

60-80 compressions per minute
100-120 compressions per minute (Correct answer)
120-140 compressions per minute
80-100 compressions per minute

Correct answer: 100-120 compressions per minute

AHA guidelines recommend high-quality CPR at a rate of 100-120 chest compressions per minute for adults to maintain adequate cardiac output.

Question 45: When assisting with a coronary artery bypass graft (CABG) procedure, the surgeon frequently harvests the left internal mammary artery (LIMA) as a conduit. The LIMA is prized for its longevity and typically arises directly from which parent artery?

Brachiocephalic trunk
Axillary artery
Subclavian artery (Correct answer)
Ascending aorta

Correct answer: Subclavian artery

The left internal mammary artery (LIMA), also known as the internal thoracic artery, is a major branch arising from the first part of the subclavian artery in the upper chest. Its anatomical position and superior long-term patency rates make it the gold standard conduit for bypassing the left anterior descending (LAD) coronary artery.

Question 46: When performing a surgical hand scrub using the anatomical (timed) method, what is the minimum required scrub duration per the Association of periOperative Registered Nurses (AORN) guidelines?

3 minutes
5 minutes (Correct answer)
1 minute
10 minutes

Correct answer: 5 minutes

AORN guidelines recommend a minimum 5-minute surgical scrub using the timed anatomical method for initial cases.

Question 47: The triangle of Calot, critical for safe cholecystectomy, is bounded superiorly by which structure?

Cystic artery
Liver (visceral surface) (Correct answer)
Cystic duct
Common hepatic duct

Correct answer: Liver (visceral surface)

The triangle of Calot is bounded superiorly by the visceral surface of the liver, medially by the common hepatic duct, and inferiorly by the cystic duct.

Question 48: Which suture material is MOST appropriate for closing a contaminated abdominal fascia when delayed healing is expected?

Plain gut
Silk
Polyglactin 910 (Vicryl)
Polypropylene (Prolene) (Correct answer)

Correct answer: Polypropylene (Prolene)

Polypropylene is a non-absorbable, monofilament suture that maintains its tensile strength indefinitely and is resistant to bacterial colonization, making it suitable for contaminated fields.

Question 49: During a procedure, the CSFA observes a circulating nurse, who is not gowned and gloved, reach over the sterile back table to retrieve an item from the far side. What is the most appropriate immediate action for the CSFA to take?

Ask the surgeon if they believe the field is still sterile.
Say nothing to avoid conflict and continue with the procedure.
Immediately state that the field has been contaminated and request that all potentially affected items be removed and replaced. (Correct answer)
Wait until the end of the procedure to report the incident to the charge nurse.

Correct answer: Immediately state that the field has been contaminated and request that all potentially affected items be removed and replaced.

A core principle of aseptic technique is that non-sterile individuals or items must never cross over the sterile field. When this occurs, the field is considered contaminated. The CSFA has a duty to advocate for patient safety by immediately identifying the breach so the team can take corrective action, which includes removing and replacing any compromised supplies or drapes.

Question 50: Which postoperative complication is MOST associated with unilateral leg swelling, warmth, and a positive Homans' sign in a patient who had a 6-hour pelvic surgery?

Compartment syndrome
Deep vein thrombosis (DVT) (Correct answer)
Lymphedema
Superficial thrombophlebitis

Correct answer: Deep vein thrombosis (DVT)

Prolonged pelvic surgery causes venous stasis, and DVT presents with unilateral limb swelling, warmth, erythema, and calf pain with dorsiflexion (Homans' sign).

Question 51: A patient taking warfarin is scheduled for elective surgery. What is the most critical preoperative concern?

Risk of malignant hyperthermia
Risk of anaphylaxis
Risk of uncontrolled bleeding (Correct answer)
Risk of infection

Correct answer: Risk of uncontrolled bleeding

Warfarin is an anticoagulant that increases bleeding risk, requiring careful bridging or reversal protocols before surgery.

Question 52: Gelatin sponge (Gelfoam) achieves hemostasis primarily by which mechanism?

Providing a scaffold for platelet aggregation and clot formation (Correct answer)
Activating the extrinsic coagulation pathway chemically
Releasing vasoconstrictors into tissue
Directly lysing red blood cells

Correct answer: Providing a scaffold for platelet aggregation and clot formation

Gelfoam acts as a physical matrix that absorbs blood and provides a surface on which platelets aggregate and fibrin polymerizes.

Question 53: During laparoscopic surgery, the surgical first assistant notes the capnography reading rising steadily. What is the most likely cause?

CO2 absorption from pneumoperitoneum (Correct answer)
Hyperventilation by the anesthesia team
Equipment malfunction in the insufflator
Patient is becoming hypothermic

Correct answer: CO2 absorption from pneumoperitoneum

CO2 used to create the pneumoperitoneum is absorbed through the peritoneum, leading to rising end-tidal CO2 on capnography.

Question 54: During a procedure, the circulating nurse accidentally touches the sterile back table with their non-sterile scrubs. The contact was brief but definite. What is the most appropriate action?

Place a sterile towel over the contaminated area.
Move sterile items away from the point of contact.
Consider the entire sterile field contaminated and replace it. (Correct answer)
Ignore the contact as it was minor.

Correct answer: Consider the entire sterile field contaminated and replace it.

The principles of aseptic technique are absolute; if a non-sterile item touches a sterile field, the field is considered contaminated. The extent of microbial transfer is unknown, and simply covering the area or moving items away does not guarantee sterility. To ensure patient safety and prevent SSI, the entire field must be broken down and a new sterile field established.

Question 55: During a laparoscopic cholecystectomy, the surgeon meticulously dissects the Triangle of Calot to safely identify and ligate the cystic artery and cystic duct. Which of the following structures forms the SUPERIOR border of this surgically important triangle?

Cystic artery
Inferior border of the liver (Correct answer)
Cystic duct
Common hepatic duct

Correct answer: Inferior border of the liver

The Triangle of Calot (or cystohepatic triangle) is a critical anatomical landmark. In modern surgical practice, it is defined by the common hepatic duct medially, the cystic duct inferiorly/laterally, and the inferior surface of the liver superiorly. The cystic artery is a content within the triangle, not a border.

Question 56: Which factor most critically determines the efficacy of sterilization by steam autoclave?

The color change of external chemical indicators on the package
The number of items loaded into the sterilizer chamber
Adequate contact of saturated steam with all surfaces at correct temperature and time (Correct answer)
The age and brand of the autoclave equipment

Correct answer: Adequate contact of saturated steam with all surfaces at correct temperature and time

Steam sterilization efficacy depends on saturated steam making direct contact with all surfaces at the correct temperature for the required time.

Question 57: A patient reports a latex allergy during preoperative assessment. The FIRST action by the surgical first assistant should be:

Cancel the surgical case immediately
Document and alert the entire surgical team to prepare a latex-free environment (Correct answer)
Proceed with surgery using standard gloves
Administer prophylactic diphenhydramine

Correct answer: Document and alert the entire surgical team to prepare a latex-free environment

Documenting and alerting the team allows preparation of a latex-free environment, the standard protocol for latex-allergic patients.

Question 58: During a total knee arthroplasty, which artery anastomosis forms the geniculate network around the knee joint?

Femoral artery and its three geniculate branches
Deep femoral artery and anterior tibial artery
Popliteal artery and its five geniculate branches (Correct answer)
Posterior tibial and peroneal arteries only

Correct answer: Popliteal artery and its five geniculate branches

The popliteal artery gives off five geniculate arteries (superior medial, superior lateral, middle, inferior medial, inferior lateral) that form the anastomotic network around the knee.

Question 59: During a thyroidectomy, the surgical first assistant must be particularly careful to identify and preserve which structure to prevent permanent hoarseness?

Hypoglossal nerve
Recurrent laryngeal nerve (Correct answer)
Glossopharyngeal nerve
Superior laryngeal nerve (external branch)

Correct answer: Recurrent laryngeal nerve

The recurrent laryngeal nerve innervates the intrinsic muscles of the larynx; bilateral injury causes permanent voice hoarseness or loss and potential airway compromise.

Question 60: During hip arthroplasty in the lateral decubitus position, injury to which nerve causes foot drop and requires careful padding and positioning?

Tibial nerve
Femoral nerve
Obturator nerve
Common peroneal nerve (Correct answer)

Correct answer: Common peroneal nerve

The common peroneal nerve wraps around the fibular neck and is compressed by positioning devices or traction in lateral decubitus, causing foot drop if injured.

Question 61: The surgical skin preparation (prep) area should extend well beyond the anticipated incision site in order to:

Allow easy placement of electrosurgical return electrode pads
Provide a sterile margin if incision boundaries need to change during surgery (Correct answer)
Enable continuous skin temperature monitoring
Improve visualization of all anatomical landmarks

Correct answer: Provide a sterile margin if incision boundaries need to change during surgery

Prepping a wide area beyond the planned incision provides a margin of sterility in case the incision must be extended or additional access sites are needed unexpectedly.

Question 62: Contact precautions are indicated for a patient infected with which of the following organisms?

Vancomycin-resistant Enterococcus (VRE) (Correct answer)
Neisseria meningitidis
Mycobacterium tuberculosis
Influenza A virus

Correct answer: Vancomycin-resistant Enterococcus (VRE)

VRE requires contact precautions — gloves and gown for all contact — because it spreads through direct contact with the patient or contaminated surfaces.

Question 63: During a laparoscopic case, the surgeon reports poor visualization due to fogging of the scope lens. What is the first corrective action?

Turn off the OR lights
Replace the CO2 canister
Warm or apply anti-fog solution to the lens before reinsertion (Correct answer)
Increase the insufflation pressure

Correct answer: Warm or apply anti-fog solution to the lens before reinsertion

Warming the scope (in warm saline or with anti-fog solution) before insertion equalizes the temperature differential that causes condensation on the lens.

Question 64: During a mastectomy with sentinel lymph node biopsy, the blue-stained lymph node is identified but appears to be in close proximity to the axillary vein. What is the first assistant's primary responsibility at this moment?

Provide meticulous retraction and clear visualization to protect the vein during dissection (Correct answer)
Inject additional blue dye to confirm mapping
Immediately clamp the node and divide it
Place a vessel loop around the axillary vein as a precaution

Correct answer: Provide meticulous retraction and clear visualization to protect the vein during dissection

The first assistant's primary role is to provide optimal retraction and exposure so the surgeon can safely dissect the sentinel node away from the axillary vein.

Question 65: The zona fasciculata of the adrenal cortex primarily produces which class of hormones?

Catecholamines
Glucocorticoids (Correct answer)
Androgens
Mineralocorticoids

Correct answer: Glucocorticoids

The zona fasciculata is the middle and largest zone of the adrenal cortex, primarily responsible for producing glucocorticoids such as cortisol.

Question 66: During a thoracotomy, the surgical first assistant is asked to place a rib retractor. After inserting the retractor, how should spreading be performed?

Place the retractor without spreading until the surgeon requests
Spread only after packing the lung with dry sponges
Spread rapidly to maximum width to reduce operative time
Spread slowly and incrementally to minimize rib fracture (Correct answer)

Correct answer: Spread slowly and incrementally to minimize rib fracture

Gradual incremental spreading reduces the risk of rib fracture and neurovascular injury between intercostal spaces.

Question 67: Which finding during a preoperative respiratory assessment would most likely cause a surgeon to delay an elective case?

History of childhood asthma, currently asymptomatic
Occasional mild dyspnea with heavy exertion
Mild seasonal allergies
Active upper respiratory infection with productive cough and fever (Correct answer)

Correct answer: Active upper respiratory infection with productive cough and fever

An active URI with productive cough and fever increases anesthesia and surgical risks; elective procedures are typically postponed.

Question 68: What is the most important goal when padding bony prominences during surgical positioning?

Using only foam padding regardless of procedure length
Keeping padding away from the incision site
Preventing pressure injuries and nerve compression (Correct answer)
Using the thinnest padding to maintain sterile field access

Correct answer: Preventing pressure injuries and nerve compression

Adequate padding of bony prominences prevents pressure injuries and nerve compression, which can cause significant postoperative morbidity.

Question 69: A patient recovering from a hip arthroplasty suddenly develops pleuritic chest pain, dyspnea, and tachycardia on postoperative day 3. The most likely diagnosis is:

Pneumothorax
Pulmonary embolism (Correct answer)
Myocardial infarction
Aspiration pneumonia

Correct answer: Pulmonary embolism

Pulmonary embolism classically presents with sudden pleuritic chest pain, dyspnea, and tachycardia following major orthopedic surgery, a high-risk period for DVT.

Question 70: During an open inguinal hernia repair, the surgeon dissects the spermatic cord. The CSFA must be aware that entrapment of a nerve that runs with the cord can lead to chronic postoperative groin pain and numbness of the upper scrotum and medial thigh. Which nerve is most at risk?

Obturator nerve
Genitofemoral nerve
Lateral femoral cutaneous nerve
Ilioinguinal nerve (Correct answer)

Correct answer: Ilioinguinal nerve

The ilioinguinal nerve travels along with the spermatic cord and provides sensation to the skin of the superomedial thigh, the root of the penis, and the upper part of the scrotum (or mons pubis and labia majora in females). It is highly vulnerable to being inadvertently sutured, entrapped in mesh, or directly injured during inguinal hernia repair, making it a primary cause of chronic post-herniorrhaphy pain.

Question 71: When educating a patient about incentive spirometry after open abdominal surgery, the surgical first assistant should instruct the patient to:

Use it only when experiencing shortness of breath
Use it 10 times every 1-2 hours while awake, holding the breath at peak inhalation (Correct answer)
Exhale forcefully into the device to expand the lungs
Use it at bedtime only to prevent respiratory fatigue

Correct answer: Use it 10 times every 1-2 hours while awake, holding the breath at peak inhalation

Incentive spirometry should be performed frequently while awake (every 1-2 hours) with sustained maximal inspiration to prevent atelectasis.

Question 72: In thoracic surgery, which structure lies immediately posterior to the esophagus in the posterior mediastinum and is at risk during esophagectomy?

Thoracic duct
Right vagus nerve
Descending thoracic aorta (Correct answer)
Azygos vein

Correct answer: Descending thoracic aorta

The descending thoracic aorta lies immediately posterior to the esophagus and can be injured during extensive esophageal mobilization.

Question 73: What is the rationale for assessing a patient's Mallampati score preoperatively?

To assess nutritional status
To predict difficulty of endotracheal intubation (Correct answer)
To determine positioning requirements
To estimate blood loss during surgery

Correct answer: To predict difficulty of endotracheal intubation

The Mallampati classification assesses oropharyngeal visibility to predict potential difficult airway and intubation challenges.

Question 74: Which parameter is monitored using a pulse oximeter?

End-tidal carbon dioxide (EtCO2)
Mixed venous oxygen saturation (SvO2)
Peripheral arterial oxygen saturation (SpO2) (Correct answer)
Partial pressure of arterial oxygen (PaO2)

Correct answer: Peripheral arterial oxygen saturation (SpO2)

Pulse oximetry measures peripheral arterial oxygen saturation (SpO2) using photoplethysmography based on light absorption differences between oxyhemoglobin and deoxyhemoglobin.

Question 75: Which clamp is most commonly used to temporarily occlude a vessel for hemostasis during vascular anastomosis?

Babcock clamp
Kocher clamp
Bulldog clamp (Correct answer)
Allis clamp

Correct answer: Bulldog clamp

Bulldog clamps (and similar atraumatic vascular clamps) apply controlled, gentle pressure to occlude vessels without crushing the vessel wall.

Question 76: The McBurney's point, used to locate the appendix, lies at what anatomical position?

Two-thirds the distance from the umbilicus to the ASIS (Correct answer)
One-third the distance from the ASIS to the umbilicus
Midpoint between the ASIS and the pubic symphysis
One-third the distance from the umbilicus to the ASIS

Correct answer: Two-thirds the distance from the umbilicus to the ASIS

McBurney's point is located two-thirds of the distance from the umbilicus to the right anterior superior iliac spine (ASIS).

Question 77: During a laparoscopic procedure, the patient's end-tidal CO2 rises to 60 mmHg. The MOST likely cause related to anesthesia/pharmacology is:

Inadequate neuromuscular blockade
Nitrous oxide diffusion into the abdomen
Opioid-induced respiratory depression (spontaneous breathing)
CO2 insufflation absorption combined with inadequate ventilation (Correct answer)

Correct answer: CO2 insufflation absorption combined with inadequate ventilation

Peritoneal CO2 insufflation is absorbed systemically; if minute ventilation is not increased, end-tidal CO2 rises significantly during laparoscopy.

Question 78: When using bipolar electrosurgery, what is the key advantage over monopolar electrosurgery?

It can cut tissue as well as coagulate
A grounding pad is still required
Higher temperatures are reached
Current travels only between the two bipolar forceps tips, limiting tissue spread (Correct answer)

Correct answer: Current travels only between the two bipolar forceps tips, limiting tissue spread

Bipolar current passes only between the two tines of the forceps, confining electrical energy to the grasped tissue and protecting surrounding structures.

Question 79: Which of the following is NOT a required element for a valid informed surgical consent?

A detailed explanation of the surgeon's experience with the procedure. (Correct answer)
A discussion of potential risks, benefits, and complications.
Information about potential alternative treatments and the consequences of no treatment.
The diagnosis and the nature and purpose of the proposed procedure.

Correct answer: A detailed explanation of the surgeon's experience with the procedure.

While a surgeon's experience is important, it is not a legally required component of the informed consent document itself. The core elements of informed consent include the patient's diagnosis, the name and description of the procedure, the risks and benefits, and a discussion of alternatives, including the option of no treatment. The patient must also have the opportunity to ask questions.

Question 80: Which muscle is responsible for plantar flexion AND inversion of the foot, making it important in clubfoot deformity correction?

Peroneus longus
Flexor digitorum longus
Tibialis anterior
Tibialis posterior (Correct answer)

Correct answer: Tibialis posterior

The tibialis posterior is a primary plantar flexor and invertor of the foot; its tendon dysfunction leads to acquired flatfoot deformity, and its overactivity contributes to clubfoot.

Question 81: The CSFA notices the surgical field is oozing excessively. The surgeon requests topical thrombin. Which statement about topical thrombin is CORRECT?

It is safe to inject intravascularly
It permanently dissolves blood clots
It must be injected IV to work effectively
It converts fibrinogen to fibrin at the surgical site (Correct answer)

Correct answer: It converts fibrinogen to fibrin at the surgical site

Topical thrombin converts fibrinogen to fibrin locally, promoting clot formation at the site of bleeding; it must never be injected intravascularly.

Question 82: When using a pneumatic tourniquet on an upper extremity, the cuff should be inflated to approximately how much above the patient's systolic blood pressure?

100 mmHg above systolic
25 mmHg above systolic
50 mmHg above systolic
75 mmHg above systolic (Correct answer)

Correct answer: 75 mmHg above systolic

For upper extremity tourniquets, inflation pressure is typically set at 50-75 mmHg above systolic blood pressure (commonly 75 mmHg) to ensure arterial occlusion without excessive pressure.

Question 83: Which preoperative positioning consideration is most critical for a patient with severe osteoporosis scheduled for a prolonged orthopedic procedure?

Positioning the patient immediately after induction without assessment
Placing the patient in steep Trendelenburg to improve venous return
Avoiding all pillow supports to keep the spine neutral
Using padding and careful positioning to prevent fractures and pressure injuries (Correct answer)

Correct answer: Using padding and careful positioning to prevent fractures and pressure injuries

Osteoporotic bones are highly susceptible to fracture under pressure; meticulous padding and gentle positioning are essential to prevent injury.

Question 84: During PACU recovery, a patient begins experiencing anginal chest pain with ST-segment elevation on the monitor. After activating the emergency response, what is the FIRST drug the PACU nurse should administer per protocol?

IV morphine
Sublingual nitroglycerin
IV heparin bolus
Aspirin 325 mg orally if not contraindicated (Correct answer)

Correct answer: Aspirin 325 mg orally if not contraindicated

Aspirin is the first-line medication for suspected acute MI as it inhibits platelet aggregation and reduces mortality.

Question 85: Which layer of the abdominal wall is closed with a running or interrupted suture using a heavy delayed-absorbable or permanent suture for fascial strength?

Skin
Peritoneum
Subcutaneous fat (Camper's fascia)
Anterior rectus fascia / aponeurosis (Correct answer)

Correct answer: Anterior rectus fascia / aponeurosis

The fascial layer (anterior rectus sheath/aponeurosis) bears the primary tension of abdominal closure and requires strong, long-lasting suture material.

Question 86: What is the purpose of applying a bolster or bumper over a tie-over dressing in skin graft surgery?

To keep the graft visible for monitoring
To apply topical antibiotics continuously
To immobilize the graft against the recipient bed, preventing hematoma and shear that disrupts neovascularization (Correct answer)
To promote early ambulation

Correct answer: To immobilize the graft against the recipient bed, preventing hematoma and shear that disrupts neovascularization

The bolster dressing maintains uniform pressure on the graft, preventing fluid accumulation and movement that would disrupt the new blood supply.

Question 87: Which preoperative assessment finding requires immediate notification to the anesthesia team and surgeon before proceeding?

Blood pressure of 128/82 mmHg
Temperature of 37.1°C (98.8°F)
Heart rate of 78 bpm
Blood glucose of 380 mg/dL in a diabetic patient (Correct answer)

Correct answer: Blood glucose of 380 mg/dL in a diabetic patient

Severely elevated blood glucose (380 mg/dL) indicates poor diabetic control and increases infection and healing risks, warranting provider notification.

Question 88: When passing a surgical specimen, such as a lymph node for frozen section, from the sterile field to the circulating nurse, what is the most critical step to ensure its integrity and prevent a diagnostic error?

Wrapping the specimen in a dry gauze sponge to absorb excess fluid.
Keeping the specimen moist with saline and confirming orientation with the surgeon. (Correct answer)
Handing it off on a countable ray-tec sponge for easy transfer.
Placing it immediately in a large container of 10% formalin.

Correct answer: Keeping the specimen moist with saline and confirming orientation with the surgeon.

Specimens for frozen section must be sent fresh, without formalin, to the pathology lab for immediate analysis. It is critical to keep the tissue from drying out, which can be done by placing it on a saline-moistened Telfa pad or in a sterile container with a few drops of saline. The CSFA must also confirm the identity and any specific orientation (e.g., marking sutures) with the surgeon before passing it off the field.

Question 89: Ketamine's primary mechanism of action as an anesthetic involves blocking which receptor?

Alpha-2 adrenergic
GABA-A
NMDA (Correct answer)
Mu-opioid

Correct answer: NMDA

Ketamine produces dissociative anesthesia by blocking NMDA (N-methyl-D-aspartate) glutamate receptors in the CNS.

Question 90: During a laparoscopic appendectomy, the surgical first assistant is using an endoscopic stapler to divide the mesoappendix. The stapler fires but the tissue appears inadequately transected. What is the correct next step?

Notify the surgeon and evaluate the staple line before proceeding (Correct answer)
Proceed with transection using monopolar scissors
Fire the stapler a second time immediately on the same tissue
Apply an endoclip across the mesoappendix proximal to the staple line

Correct answer: Notify the surgeon and evaluate the staple line before proceeding

A misfire or incomplete staple line requires stopping to assess the situation with the surgeon before any further action to prevent hemorrhage or incomplete division.

Question 91: Which type of shock is characterized by warm, flushed skin, bounding pulses, and low systemic vascular resistance in the early phase?

Hypovolemic shock
Cardiogenic shock
Obstructive shock
Distributive (septic) shock (Correct answer)

Correct answer: Distributive (septic) shock

Early distributive shock (septic) presents with vasodilation, causing warm flushed skin and bounding pulses due to decreased systemic vascular resistance.

Question 92: During a shoulder arthroscopy performed in the beach chair position, the patient's blood pressure drops significantly. The CSFA and surgical team should be most concerned about which specific position-related complication?

Cerebral hypoperfusion (Correct answer)
Venous thromboembolism
Brachial plexus injury
Sciatic nerve damage

Correct answer: Cerebral hypoperfusion

In the upright beach chair position, a hydrostatic gradient exists between the heart (where a blood pressure cuff is typically placed) and the brain. A normal blood pressure reading at the arm may correspond to a dangerously low perfusion pressure in the brain, leading to cerebral hypoperfusion and potential ischemic injury.

Question 93: During a posterior approach to the hip, which nerve is most at risk from excessive internal rotation or retraction?

Femoral nerve
Superior gluteal nerve
Sciatic nerve (Correct answer)
Obturator nerve

Correct answer: Sciatic nerve

The sciatic nerve exits the greater sciatic foramen and lies posterior to the hip, making it vulnerable during posterior hip approaches.

Question 94: A postoperative patient develops sudden-onset confusion, contralateral facial droop, and arm weakness. The surgical first assistant suspects a stroke. What is the priority action?

Administer IV tPA without delay
Obtain a head CT and administer aspirin immediately
Activate the stroke protocol and note the exact time of symptom onset (Correct answer)
Lower the blood pressure to below 120/80 mmHg urgently

Correct answer: Activate the stroke protocol and note the exact time of symptom onset

Activating the stroke team and recording exact symptom onset time are critical because eligibility for reperfusion therapy depends on the time window.

Question 95: When using a monopolar electrosurgical unit near a nerve, what technique minimizes the risk of thermal injury to adjacent neural structures?

Increase the distance of the dispersive electrode
Use higher power settings for shorter bursts
Apply current in continuous mode only
Use bipolar electrosurgery instead (Correct answer)

Correct answer: Use bipolar electrosurgery instead

Bipolar electrosurgery confines current between the two tips, limiting the spread of thermal energy to surrounding tissues including nerves.

Question 96: When using a harmonic scalpel (ultrasonic energy device), the surgical first assistant should avoid:

Using it for soft tissue dissection
Applying it to fatty tissue
Activating it while the blade is in contact with metal clips or other instruments (Correct answer)
Using it near vascular pedicles

Correct answer: Activating it while the blade is in contact with metal clips or other instruments

Activating an ultrasonic device while touching metal can transfer energy to unintended structures, causing burns or device damage.

Question 97: When tying a surgeon's knot, how does the first throw differ from a standard square knot?

The first throw uses a single loop only
The first throw is made with the non-dominant hand only
The first throw wraps twice around the needle holder (double throw) for added friction to prevent slipping (Correct answer)
The first throw passes the suture through the tissue twice

Correct answer: The first throw wraps twice around the needle holder (double throw) for added friction to prevent slipping

A surgeon's knot starts with a double throw (two wraps) on the first pass, creating extra friction that holds the loop in place while the second throw is placed.

Question 98: Which electrosurgical mode uses an interrupted, modulated current that produces a coagulating effect with minimal cutting?

Cut mode
Blend mode
Bipolar mode
Coagulation mode (Correct answer)

Correct answer: Coagulation mode

Coagulation mode delivers an interrupted, modulated waveform at a lower duty cycle, producing tissue desiccation and hemostasis rather than vaporization.

Question 99: When closing a midline laparotomy incision using a running suture, what suture-to-wound length ratio is recommended to minimize dehiscence?

4:1 (Correct answer)
1:1
6:1
2:1

Correct answer: 4:1

A suture-to-wound length ratio of at least 4:1 is evidence-based and associated with the lowest rates of incisional hernia and wound dehiscence.

Question 100: A biologic indicator (BI) used to monitor the efficacy of a steam sterilization cycle contains spores from which microorganism?

Clostridium difficile
Geobacillus stearothermophilus (Correct answer)
Mycobacterium tuberculosis
Bacillus atrophaeus

Correct answer: Geobacillus stearothermophilus

Biological indicators are the most reliable method for monitoring sterilization efficacy because they directly test the lethality of the process. For steam sterilization, BIs contain spores of Geobacillus stearothermophilus, a thermophilic bacterium that is highly resistant to moist heat, ensuring that if it is killed, less resistant organisms have also been eliminated.

Question 101: The surgical first assistant is asked to assist with hemostasis using a harmonic scalpel. This device achieves coagulation through which mechanism?

Cryotherapy and vasoconstriction
Ultrasonic vibration causing protein denaturation (Correct answer)
Laser energy absorbed by hemoglobin
High-frequency electrical current

Correct answer: Ultrasonic vibration causing protein denaturation

The harmonic scalpel uses ultrasonic vibrations at 55,500 Hz to denature proteins, coagulate vessels, and cut tissue simultaneously without passing electrical current through the patient.

Question 102: During retraction of the bowel, which technique best prevents serosal injury?

Applying towel clips to bowel walls for traction
Packing moist laparotomy sponges around bowel before applying retractors (Correct answer)
Using electrocautery to retract tissue
Using sharp Richardson retractors directly on bowel loops

Correct answer: Packing moist laparotomy sponges around bowel before applying retractors

Moist laparotomy sponges cushion and protect the bowel serosa from injury by mechanical retractors.

Question 103: A patient who underwent total knee replacement is on a multimodal pain regimen including scheduled acetaminophen, celecoxib, and PRN oxycodone. This approach is designed primarily to:

Comply with hospital formulary requirements
Reduce the risk of acetaminophen hepatotoxicity
Eliminate the need for any opioid medications postoperatively
Minimize opioid consumption by targeting multiple pain pathways (Correct answer)

Correct answer: Minimize opioid consumption by targeting multiple pain pathways

Multimodal analgesia combines agents with different mechanisms to achieve superior pain control while reducing opioid-related side effects.

Question 104: A 68-year-old male is scheduled for an elective total knee arthroplasty. He has a history of atrial fibrillation and has been on a direct oral anticoagulant (DOAC). According to current guidelines for a high-bleed-risk surgery, what is the most appropriate instruction regarding his anticoagulation medication?

Bridge with low-molecular-weight heparin starting 5 days before surgery.
Continue the DOAC until the morning of surgery.
Stop the DOAC 7 days prior to surgery.
Stop the DOAC 2 days before the procedure and skip it on the day of and the day after surgery. (Correct answer)

Correct answer: Stop the DOAC 2 days before the procedure and skip it on the day of and the day after surgery.

For high-bleed-risk surgeries, such as a total knee arthroplasty, direct oral anticoagulants (DOACs) are typically stopped 2 days before the procedure. The medication is also held on the day of surgery and the day immediately following to minimize the risk of significant perioperative bleeding. Bridging therapy is not routinely recommended for DOACs due to their shorter half-life compared to warfarin.

Question 105: During a posterolateral thoracotomy, the surgical first assistant retracts which muscle that originates from the lower six ribs and inserts on the iliac crest and thoracolumbar fascia?

Rhomboid major
External intercostal
Latissimus dorsi (Correct answer)
Serratus anterior

Correct answer: Latissimus dorsi

The latissimus dorsi is the large, flat muscle typically divided or retracted during posterolateral thoracotomy to access the thoracic cavity.

Question 106: Which positioning device is most effective in preventing patient sliding during steep Trendelenburg position?

Standard arm boards alone
A vacuum bean bag or padded shoulder braces (Correct answer)
Wrist restraints only
Leg restraints secured at the ankles

Correct answer: A vacuum bean bag or padded shoulder braces

Vacuum bean bags or padded shoulder braces are the most effective devices for preventing cephalad patient migration during steep Trendelenburg positioning.

Question 107: During a thyroidectomy, inadvertent injury to which structure would most likely result in immediate hoarseness?

Phrenic nerve
Ansa cervicalis
Recurrent laryngeal nerve (Correct answer)
External branch of the superior laryngeal nerve

Correct answer: Recurrent laryngeal nerve

The recurrent laryngeal nerve innervates the intrinsic laryngeal muscles responsible for vocal cord movement; injury causes immediate hoarseness.

Question 108: Postoperative oliguria is defined as urine output less than:

0.5 mL/kg/hr (Correct answer)
0.1 mL/kg/hr
1.0 mL/kg/hr
1.5 mL/kg/hr

Correct answer: 0.5 mL/kg/hr

Oliguria is defined as urine output less than 0.5 mL/kg/hr and indicates potentially inadequate renal perfusion.

Question 109: A patient undergoing open abdominal surgery develops sudden hypotension and tachycardia midway through the procedure. The first assistant notices the surgical field is dry. What should be suspected?

Internal hemorrhage not visible in the field
Anesthetic overdose
Vasovagal response
Pulmonary embolism (Correct answer)

Correct answer: Pulmonary embolism

Sudden intraoperative hypotension with tachycardia and a dry field should raise suspicion for pulmonary embolism, especially in prolonged procedures.

Question 110: During a right hemicolectomy, the surgical first assistant is assisting with the ileocolic anastomosis. The MOST important factor in reducing anastomotic leak risk is ensuring:

The bowel is clamped distally before suturing
The anastomosis is completed in under 15 minutes
Double-layer suture technique is always used
Adequate blood supply and tension-free anastomosis (Correct answer)

Correct answer: Adequate blood supply and tension-free anastomosis

Anastomotic integrity depends primarily on adequate vascular perfusion and absence of tension; ischemia or tension are the leading causes of anastomotic breakdown.

Question 111: Which surgical specialty case would most likely be classified as a clean-contaminated (Class II) wound?

Inguinal hernia repair with no bowel involvement
Exploratory laparotomy for a perforated appendix with peritoneal soilage
Elective sigmoid colectomy with bowel entered under controlled conditions (Correct answer)
Debridement of an infected pressure ulcer

Correct answer: Elective sigmoid colectomy with bowel entered under controlled conditions

Elective colon surgery with controlled entry into the GI tract without gross spillage meets the criteria for Class II clean-contaminated wounds.

Question 112: A patient with suspected Creutzfeldt-Jakob disease (CJD) undergoes a brain biopsy. According to CDC and WHO guidelines, which of the following is the most appropriate method for handling the involved surgical instruments?

Standard steam sterilization followed by immediate reuse.
Immediate-use steam sterilization (IUSS) in the sub-sterile room.
Segregation, followed by either incineration or a combination of chemical soaking and extended steam sterilization cycles. (Correct answer)
Low-temperature hydrogen peroxide gas plasma sterilization.

Correct answer: Segregation, followed by either incineration or a combination of chemical soaking and extended steam sterilization cycles.

Prions, the causative agents of CJD, are highly resistant to conventional sterilization methods. Guidelines from the CDC and WHO recommend that instruments used on high-infectivity tissue from a known or suspected CJD patient should ideally be incinerated. If not incinerated, they must undergo specific, rigorous decontamination protocols, such as soaking in sodium hydroxide (NaOH) or sodium hypochlorite followed by an extended steam sterilization cycle (e.g., 134°C for 18 to 60 minutes). Standard cycles, IUSS, and gas plasma are ineffective against prions.

Question 113: A postoperative patient on a beta-blocker develops a heart rate of 48 bpm, blood pressure of 88/54 mmHg, and is symptomatic with dizziness. The MOST appropriate pharmacologic intervention is:

Amiodarone for rate control
Metoprolol IV to support cardiac conduction
Digoxin to improve contractility
Atropine IV for symptomatic bradycardia (Correct answer)

Correct answer: Atropine IV for symptomatic bradycardia

Atropine is the first-line treatment for symptomatic bradycardia by blocking vagal tone to increase heart rate.

Question 114: Ondansetron is frequently used perioperatively to prevent PONV. Its mechanism of action involves blocking which receptor?

Histamine H1
Muscarinic M1
Dopamine D2
Serotonin 5-HT3 (Correct answer)

Correct answer: Serotonin 5-HT3

Ondansetron is a selective 5-HT3 receptor antagonist that blocks serotonin-mediated signals in the chemoreceptor trigger zone and GI tract.

Question 115: A 68-year-old patient is on postoperative day 1 after a total hip arthroplasty. The patient is receiving prophylactic anticoagulants. In addition to medication, which of the following interventions is most crucial for the CSFA to encourage to help prevent deep vein thrombosis (DVT)?

Early and frequent ambulation as tolerated. (Correct answer)
Maintaining strict bed rest with legs elevated.
Limiting fluid intake to reduce peripheral edema.
Application of continuous cold therapy to the operative leg.

Correct answer: Early and frequent ambulation as tolerated.

Early ambulation is a cornerstone of DVT prevention following major orthopedic surgery. [4] The contraction of calf muscles during walking actively pumps venous blood, preventing the stasis that contributes to clot formation (one part of Virchow's triad). While pharmacological prophylaxis is essential, early mobilization is a critical mechanical method of prevention. [4, 13] Strict bed rest significantly increases the risk of DVT.

Question 116: When positioning a patient in the prone position, which combination of areas requires the most vigilant pressure injury protection?

Only the knees and elbows
Occiput and heels only
Eyes, ears, breasts (women), genitalia (men), and bony prominences (Correct answer)
The abdomen and thorax only

Correct answer: Eyes, ears, breasts (women), genitalia (men), and bony prominences

In the prone position, the eyes, ears, breasts, male genitalia, and all bony prominences must be carefully padded and protected from direct pressure.

Question 117: A patient who had a Whipple procedure (pancreaticoduodenectomy) 3 days ago develops fever, leukocytosis, and a new onset of abdominal pain. Drain amylase levels are elevated 3x the upper limit of normal. This is MOST consistent with:

Pancreatic fistula/leak (Correct answer)
Wound infection
Delayed gastric emptying
Intra-abdominal abscess

Correct answer: Pancreatic fistula/leak

Elevated drain amylase greater than 3x the upper limit of normal on postoperative day 3 or later is the diagnostic criterion for a postoperative pancreatic fistula.

Question 118: During a bowel resection, the surgical first assistant uses a linear stapler. The color-coded staple cartridge used for thick tissue such as bowel is MOST likely:

Blue (3.5 mm staples)
Green (4.8 mm staples) (Correct answer)
Gold (4.1 mm staples)
White (2.5 mm staples)

Correct answer: Green (4.8 mm staples)

Green cartridges contain 4.8 mm staples designed for thick tissue such as bowel and lung parenchyma, providing adequate compression without tissue necrosis.

Question 119: Which medication is administered to prevent bradycardia when succinylcholine is used in pediatric patients?

Epinephrine
Atropine (Correct answer)
Glycopyrrolate
Neostigmine

Correct answer: Atropine

Atropine is given prior to succinylcholine in children to prevent the profound bradycardia that succinylcholine can cause in the pediatric population.

Question 120: Which benzodiazepine is most commonly used for preoperative anxiolysis and procedural sedation due to its short duration and amnestic properties?

Clonazepam
Diazepam
Lorazepam
Midazolam (Correct answer)

Correct answer: Midazolam

Midazolam is preferred for perioperative use because of its short half-life, reliable anxiolysis, and potent anterograde amnesia.

Question 121: What is the correct sequence for surgical hand antisepsis using a surgical hand scrub?

Scrub hands, then wrists, then forearms up to 2 inches above the elbow
Scrub forearms first, then wrists, then hands and nails last
Scrub fingernails and subungual areas first, then hands, wrists, and forearms (Correct answer)
Scrub hands and forearms simultaneously using circular motions

Correct answer: Scrub fingernails and subungual areas first, then hands, wrists, and forearms

Surgical hand antisepsis begins with subungual areas and nails (highest microbial load), then progresses distally to proximally through hands, wrists, and forearms.

Question 122: Which gas is most commonly used for laparoscopic insufflation, and why?

Nitrogen — provides the longest working time
Nitrous oxide — cheapest available gas
Carbon dioxide — rapidly absorbed, non-combustible, and inexpensive (Correct answer)
Oxygen — because it supports combustion and is inert

Correct answer: Carbon dioxide — rapidly absorbed, non-combustible, and inexpensive

CO2 is preferred because it is non-flammable (safe with electrosurgery), rapidly absorbed by tissues if a gas embolism occurs, and cost-effective.

Question 123: Which preoperative measure is most important when preparing a patient with a known difficult airway?

Ensuring availability of difficult airway equipment and a backup airway plan (Correct answer)
Scheduling the case at the start of the day only
Administering a sedative premedication to relax the patient
Applying a cervical collar for stability

Correct answer: Ensuring availability of difficult airway equipment and a backup airway plan

For difficult airway patients, the team must ensure specialized equipment (video laryngoscope, LMA, surgical airway tools) and a clear backup plan are ready.

Question 124: What is the most common pulmonary complication experienced by patients within the first 48 hours following major abdominal or thoracic surgery?

Pneumonia
Pneumothorax
Pulmonary Embolism
Atelectasis (Correct answer)

Correct answer: Atelectasis

Atelectasis, the collapse of alveoli, is the most frequent postoperative pulmonary complication, especially within the first 48 hours. [7, 16, 18] It is primarily caused by shallow breathing due to pain, residual effects of anesthesia, and patient immobility. It is the primary reason for encouraging incentive spirometry, deep breathing exercises, and early ambulation. While atelectasis can lead to pneumonia, it is the initial and more common event. [16]

Question 125: Which of the following terms describes the complete separation of all layers of a surgical wound with the protrusion of internal organs?

Dehiscence
Evisceration (Correct answer)
Hematoma
Fistula

Correct answer: Evisceration

Evisceration is a surgical emergency defined as the separation of all fascial layers of a wound accompanied by the protrusion of intra-abdominal organs. [2, 6, 9] Dehiscence refers to the separation of wound layers without organ protrusion. [9, 20] A hematoma is a collection of blood, and a fistula is an abnormal connection between two body parts.

Question 126: Which antiseptic preparation requires a minimum drying and contact time before incision to achieve maximum antiseptic effect and to prevent surgical fire risk?

Chlorhexidine gluconate with alcohol (e.g., ChloraPrep) (Correct answer)
Aqueous benzalkonium chloride
Povidone-iodine scrub solution
Triclosan-based surgical soap

Correct answer: Chlorhexidine gluconate with alcohol (e.g., ChloraPrep)

Alcohol-based chlorhexidine preparations must dry completely before draping; the alcohol evaporation eliminates fire risk and the drying time ensures antimicrobial efficacy.

Question 127: During a Whipple procedure (pancreaticoduodenectomy), which structure must be carefully preserved to maintain venous drainage of the remnant pancreas?

Inferior mesenteric vein
Splenic vein
Superior mesenteric vein (Correct answer)
Portal vein

Correct answer: Superior mesenteric vein

The superior mesenteric vein runs posterior to the neck of the pancreas and must be preserved to allow venous drainage of the pancreatic remnant.

Question 128: Spinal anesthesia is administered for a lower extremity procedure. The CSFA should be prepared for which MOST common immediate complication?

Hyperglycemia
Malignant hyperthermia
Bronchospasm
Hypotension due to sympathetic blockade (Correct answer)

Correct answer: Hypotension due to sympathetic blockade

Spinal anesthesia blocks sympathetic fibers, causing vasodilation and venous pooling that results in a rapid drop in blood pressure.

Question 129: Which bone kind is longer than it is wide?

Sesamoid bones
Long bones (Correct answer)
Short bone
All the answers are correct.

Correct answer: Long bones

Long bones are a classification of bones characterized by their length being significantly greater than their width. They typically consist of a long, slender shaft (diaphysis) and two expanded ends (epiphyses). Examples include the femur, tibia, and humerus, which are crucial for support, movement, and leverage in the body.

Question 130: To prevent brachial plexus injury in the supine position, the surgical first assistant should ensure:

The arm is hyperextended at the elbow
The arm board is at or below shoulder level and arm abduction does not exceed 90 degrees (Correct answer)
The arm is raised above the patient's head for the entire procedure
The arm is tucked tightly against the patient's side without padding

Correct answer: The arm board is at or below shoulder level and arm abduction does not exceed 90 degrees

Limiting arm abduction to no more than 90 degrees and keeping the arm board at or below shoulder level prevents stretching and injury to the brachial plexus.

Question 131: The hepatoduodenal ligament (free edge of the lesser omentum) contains all of the following EXCEPT:

Common bile duct
Hepatic veins (Correct answer)
Portal vein
Hepatic artery proper

Correct answer: Hepatic veins

The hepatic veins drain directly into the inferior vena cava at the liver and are not contained within the hepatoduodenal ligament.

Question 132: The prone position with arms extended forward on arm boards (resembling a flying posture) is most commonly called:

Superman (prayer) position (Correct answer)
Standard prone with lateral arm boards
Jackknife (Kraske) position
Modified Fowler position

Correct answer: Superman (prayer) position

The Superman or prayer position places the prone patient with arms extended forward on arm boards, used for certain cervical spine and posterior thoracic procedures.

Question 133: Which of the following is considered a 'passive' or 'mechanical' topical hemostatic agent that works by absorbing blood and providing a physical matrix for clot formation?

Topical Thrombin
Regenerated Oxidized Cellulose (Correct answer)
Tranexamic Acid (TXA)
Epinephrine solution

Correct answer: Regenerated Oxidized Cellulose

Regenerated oxidized cellulose (e.g., Surgicel) is a passive hemostatic agent. It does not contain active clotting factors but instead provides a physical scaffold that absorbs blood and promotes platelet aggregation, facilitating the natural clotting cascade. Topical thrombin is an active biological agent, TXA is an antifibrinolytic, and epinephrine is a vasoconstrictor.

Question 134: What distinguishes a figure-of-eight suture from a simple interrupted suture?

It passes through tissue twice in a crossing pattern, distributing tension over a wider area (Correct answer)
It is tied before placement
It uses absorbable material exclusively
It is placed subcutaneously only

Correct answer: It passes through tissue twice in a crossing pattern, distributing tension over a wider area

A figure-of-eight suture crosses over itself, engaging tissue at two points and distributing closure tension more broadly than a simple interrupted suture.

Question 135: Which postoperative electrolyte imbalance is MOST commonly associated with cardiac arrhythmias and is a known risk following prolonged nasogastric suctioning?

Hypocalcemia
Hypokalemia (Correct answer)
Hypermagnesemia
Hypernatremia

Correct answer: Hypokalemia

Prolonged NG suctioning removes gastric fluid rich in potassium and hydrogen ions, leading to hypokalemia and metabolic alkalosis that predispose to arrhythmias.

Question 136: What is the primary purpose of performing a surgical site mark preoperatively?

To guide anesthesia needle placement
To indicate where the incision will be closed
To identify vascular access sites
To prevent wrong-site surgery (Correct answer)

Correct answer: To prevent wrong-site surgery

Surgical site marking is a Joint Commission Universal Protocol requirement to prevent wrong-site, wrong-procedure, wrong-person surgery.

Question 137: When assisting with a bowel anastomosis, which layer is sutured first in a two-layer technique?

Mucosal layer (Correct answer)
Seromuscular layer
Submucosal layer
Mesenteric layer

Correct answer: Mucosal layer

In a two-layer anastomosis, the inner mucosal layer is sutured first, followed by the outer seromuscular layer.

Question 138: During a right hemicolectomy, the ileocolic artery is divided. Which structure must the surgical first assistant be careful to avoid injuring during retroperitoneal dissection at this step?

Right ureter as it crosses over the iliac vessels (Correct answer)
Superior mesenteric vein
Inferior mesenteric artery
Gonadal vessels

Correct answer: Right ureter as it crosses over the iliac vessels

The right ureter runs retroperitoneally and crosses over the right iliac vessels; it is at risk during right colectomy mesenteric dissection.

Question 139: Which retractor is BEST suited for providing self-retaining exposure during an open abdominal procedure?

Bookwalter retractor (Correct answer)
Army-Navy retractor
Deaver retractor
Richardson retractor

Correct answer: Bookwalter retractor

The Bookwalter is a self-retaining retractor system that attaches to the operating table and provides hands-free abdominal exposure without requiring an assistant to hold it.

Question 140: During a radical nephrectomy, the left renal vein receives which additional tributaries not present on the right?

Left gonadal vein only
Left gonadal vein and left adrenal vein (Correct answer)
Left adrenal vein and hemiazygos vein
Inferior mesenteric vein only

Correct answer: Left gonadal vein and left adrenal vein

The left renal vein receives the left gonadal (testicular/ovarian) vein and left adrenal vein, which drain directly into it rather than the IVC.

Question 141: Which type of surgical drain relies on gravity and capillary action for passive drainage, without suction?

Jackson-Pratt (JP) drain
Penrose drain (Correct answer)
Hemovac drain
Blake drain

Correct answer: Penrose drain

The Penrose drain is a flat latex tube that drains passively by gravity and capillary action, without a reservoir or vacuum, and exits through a dependent portion of the wound.

Question 142: A patient on chronic warfarin therapy requires emergent surgery. Which product provides the FASTEST reversal of warfarin's anticoagulant effect?

Fresh frozen plasma
Vitamin K (oral)
4-factor prothrombin complex concentrate (PCC) (Correct answer)
Platelet transfusion

Correct answer: 4-factor prothrombin complex concentrate (PCC)

4-factor PCC provides immediate replenishment of all vitamin K-dependent clotting factors, offering faster reversal than FFP or oral vitamin K.

Question 143: Which retroperitoneal structure crosses the pelvic brim at the bifurcation of the iliac vessels and is at risk during pelvic surgery?

Ureter (Correct answer)
Obturator nerve
Ilioinguinal nerve
Femoral nerve

Correct answer: Ureter

The ureter crosses the pelvic brim at the bifurcation of the common iliac artery, making it vulnerable during pelvic dissections such as hysterectomy and colorectal resections.

Question 144: Which meningeal layer closely adheres to the brain surface and follows all gyri and sulci?

Dura mater
Pia mater (Correct answer)
Arachnoid mater
Periosteal layer

Correct answer: Pia mater

The pia mater is the innermost and most delicate meningeal layer, closely adherent to the brain surface and dipping into every sulcus and fissure.

Question 145: When should the surgical hand antisepsis (surgical scrub) be performed?

After gowning but before gloving
Immediately before donning sterile gloves only if gloves are torn
Before every surgical procedure, prior to gowning and gloving (Correct answer)
Only when the surgeon's hands are visibly soiled

Correct answer: Before every surgical procedure, prior to gowning and gloving

Surgical hand antisepsis must be performed before every procedure and before gowning and gloving to reduce transient and resident flora.

Question 146: The surgical first assistant notices the patient's urine output has dropped to less than 0.5 mL/kg/hr during a prolonged abdominal case. What is the most appropriate immediate action?

Alert the anesthesia team to assess volume status and perfusion (Correct answer)
Increase the patient's intraabdominal pressure to improve renal perfusion
Clamp the Foley catheter to allow the bladder to fill
Administer furosemide 40 mg IV immediately

Correct answer: Alert the anesthesia team to assess volume status and perfusion

Oliguria during surgery signals possible hypovolemia or inadequate renal perfusion and should be immediately communicated to anesthesia for assessment and volume optimization.

Question 147: During a thyroidectomy, which structure must be identified to prevent hypocalcemia postoperatively?

Thoracic duct
Cervical sympathetic chain
Parathyroid glands (Correct answer)
External branch of superior laryngeal nerve

Correct answer: Parathyroid glands

Inadvertent removal or devascularization of the parathyroid glands leads to postoperative hypocalcemia due to loss of PTH secretion.

Question 148: Which muscle forms the floor of the femoral triangle and lies deep to the femoral vessels?

Pectineus
Iliopsoas (Correct answer)
Sartorius
Adductor longus

Correct answer: Iliopsoas

The iliopsoas muscle forms the floor of the lateral portion of the femoral triangle, with the pectineus forming the medial floor.

Question 149: Postoperative nausea and vomiting (PONV) is MOST likely to occur in which patient population?

Female nonsmokers with a history of PONV receiving opioid analgesia (Correct answer)
Elderly male patients undergoing regional anesthesia
Pediatric patients undergoing orthopedic surgery under spinal anesthesia
Male smokers undergoing short ambulatory procedures

Correct answer: Female nonsmokers with a history of PONV receiving opioid analgesia

Female sex, nonsmoker status, history of PONV or motion sickness, and postoperative opioid use are the four major independent risk factors for PONV.

Question 150: Biological indicators (BIs) used to monitor steam sterilization contain spores of which organism?

Clostridium difficile
Geobacillus stearothermophilus (Correct answer)
Bacillus atrophaeus
Bacillus anthracis

Correct answer: Geobacillus stearothermophilus

Geobacillus stearothermophilus spores are highly resistant to steam and are the standard BI for monitoring steam sterilization efficacy.

CSFA (Certified Surgical First Assistant) Exam

The CSFA (Certified Surgical First Assistant) Exam exam validates essential knowledge and skills required for certification or licensure in this field.

150

Questions

180 min

Time Limit

70%

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